NEWSROOM
March
11, 2020
Better outcomes, lower costs through community
partnerships. That was the message last week when over 150 leaders from across
America gathered in our nation’s capital for the National Summit on Health Care
and Social Service Integration. Across the country, 385 additional colleagues
joined the Summit through a live webcast.
Energy grew throughout the day as speakers and
participants spoke honestly about practical and conceptual aspects of
integrating health care and social services. Many questions from the audience
reflected the same aspirations and concerns that I have heard during
discussions with colleagues over the past year. Without doubt, the changes we
discussed represent a significant moment in American history, one that is too
important to miss.
The meeting was opened by HHS Secretary Azar’s
Senior Advisor for Health Reform, Jim Parker, who explained the need to be
flexible as we integrate health care and social services. He stated, “Just like
every healthcare patient presents differently, every person has unique social
service needs.” He also announced ACL's $500,000 prize competition that will help create
interoperable referral and analytics solutions that connect individuals to
social services and can be scaled across communities.
The audience next heard from Demetrios
Kouzoukas, Principal Deputy Administrator for the Centers for Medicare and
Medicaid Services and Director of the Center for Medicare. He defined the
primary driver for Medicare this way: “Everything we are doing in
Medicare is designed…to make sure the patient, or customer, is in charge.” He
then went on to explain the importance of coupling social services and health
care, particularly for people with chronic conditions.
Following the keynote speeches, several panels
and four breakout sessions brought out the array of successes and challenges on
the road to health care-social services integration. It’s impossible to recap
each presentation in this blog, but some key themes emerged from the day.
First, it was clear that payers, health care
providers, and community-based organizations (CBOs) were all in agreement that
this integration needs to happen. In fact, in many places across the country,
it is well underway. The conversation at this stage is about how we proceed in
a way that better aligns efforts across health plans, health systems, and
community partners to build capacity and scale integration within and across
communities. Dr. Tim Ferris, CEO of Massachusetts General Physicians
Organization and leader of an accountable care organization (ACO), commented on
the complexity of value-based care with different arrangements across payers.
He noted that busy inter-disciplinary care teams prefer to collaborate with one
community partner for care management and service coordination instead of many
plan-specific care managers. Simplification such as this was a theme that was
reiterated throughout the day. Simplification was described in the following
contexts: (a) one trusted community lead or “trusted broker,” (b) replicating
successful models of integration, (c) straight-forward contracting between
health care and CBOs, and (d) simplification through a common assessment
instrument and data standards.
The second theme was the need for multi-payer
financing of social services in the context of value-based payment. Although
everyone was not in agreement about whether CBOs should be expected to assume
financial risk over time as their health care partners assume that risk, it was
clear that there should be multiple sources of financing in a given community
that could support both capacity building and sustainability over time. For
example, a Community-Integrated Health Network of
CBOs could contract with Medicaid Managed Care Organizations, Medicare
Advantage Organizations, and Medicare Accountable Care Organizations all in the
same market to provide Social Determinants of Health (SDOH) assessments, case
management, and home-and community-based services that address each
beneficiary’s social risks. There was also agreement that all payers
should have a common community infrastructure they all buy into and rely on.
This approach reinforces what is already happening in some markets, where
Community Integrated Health Networks that deliver social services through a
network of CBOs are contracting with multiple payers.
Third, it was clear that CBOs are partnering
with health care at a community, state, and national level. The ability for
Community Integrated Health Networks to act as a trusted broker of services
through strong local connections is important. It is evident that these
networks are increasingly statewide to meet the needs of Medicaid and programs
for Medicare and Medicaid dual eligible beneficiaries, although they still
maintain the specialized knowledge and connections within local communities.
Most recently, these community networks are spanning across states and in some
cases being organized by a Management Service Organization that has a single
contract at an enterprise level with a large national health plan. As these
partnerships mature and replicate, many noted the importance of community-based
organizations maintaining their core identities, mission, and local
connections.
Summit attendees also discussed five guiding
principles regarding health care-social services integration: trust,
co-leadership, accountability, sustainability, and innovation. Real-time
polling of the audience demonstrated wide agreement on the importance of these
principles. The discussion that followed the poll brought up the diverse ways
of funding the efforts, and the need for funding to come from many places, not
just health care. Another suggestion that will be incorporated into the next
version of the principles is that we need to be accountable to the people we
serve, and not limit the focus on accountability for performance under a health
care contract. The dialog informed important refinements to the five
principles, and will help guide our collective efforts moving forward.
ACL Administrator and Assistant Secretary for
Aging Lance Robertson chaired a lunchtime panel that included Brad Smith,
Director of CMS’s Center for Medicare and Medicaid Innovation, and Dawn Alley,
HHS’s Deputy Senior Advisor for Value-based Transformations. They shared their
views about SDOH innovation and the ways CMMI models are encouraging the
integration of health care and social services. Brad highlighted how the Direct Contracting model is encouraging
partnerships with Area Agencies on Aging and Centers for Independent Living in
addressing social needs. They also noted the importance of braiding and
blending of funds, given the significant federal and state expenditures related
to housing, transportation, and nutrition assistance.
The panel on the role of state government in
social determinants of health, chaired by ACL’s Principal Deputy Administrator
Mary Lazare, revealed the diversity of integration approaches employed by
different states. Calder Lynch, Deputy Administrator and Director of the Center
for Medicaid and CHIP Services, spoke about the existing opportunities under
Medicaid authorities to address SDOH under 1915, 1115 waivers, and Medicaid
managed care. The importance of coordination across Medicaid, aging, and
disability was discussed. Massachusetts Executive Office of Elder Affairs
Secretary Elizabeth Chen described how an 1115 waiver allowed the state to
implement Medicaid ACOs with a requirement to collaborate with community-based
organizations to prevent health care organizations from transferring the
community workforce to their own institutions. She referred to the importance
of health care “buying” the existing community based services vs. “building”
the capacity in-house, which Dr. Bruce Chernof and Lance Robertson wrote about
in a recent Health Affairs blog. Our
country has invested for many decades in the social services network, and
integrating that network with health care – not building a new solution for
each health care organization – makes a lot of sense.
It was exciting to see an action agenda emerge
from four break-out sessions and to listen as the closing panel synthesized the
critical steps we will need to take to make further progress. Regarding
financing social care, a near-term recommended action item was to clarify
whether payers can count SDOH case management and services that are
incorporated into the healthcare delivery towards the medical portion of the
medical loss ratio (MLR) and total cost of care. A related near-term action was
to test, and potentially replicate, a multi-payer model for common care
management services offered by CBOs or a Community Integrated Health Network,
where these care management services could be billed with existing Medicare
codes or count in the numerator of an MLR. There was strong agreement on an
action to define requirements for Community Integrated Health Networks that
could then be tied to state and federal policy levers to encourage ongoing
financing of SDOH services delivered through these networks. There was also a
desire expressed to build the evidence base on impactful SDOH interventions
while replicating the integration of CBOs into health care without requiring
randomized controlled trials as a bar for evidence prior to scaling. The sense
of urgency and the window of opportunity can best be met by rapid cycle
evaluation informing replication and scale of successful integration.
The Summit could not have succeeded without our
panel moderators and members. We thank each of them: Melinda Abrams, Dawn Alley,
Connie Benton Wolfe, James “Jay” Bulot, Elizabeth Chen, Bruce Chernof, Curtis
Cunningham, Melinda Dutton, Timothy Ferris, Mary Lazare, Calder Lynch, Sandy
Markwood, Tim McNeill, Andy McMahon, Kevin Moore, Jacob Reider, Walter Saurez,
June Simmons, Brad Smith, Jim Vandagrifft, Kathy Vesley, and Ginger
Wettingfeld.
The main thought I came away with from the
summit was that creativity and determination can overcome any obstacles. As we,
together, move further into the integration of social services and health care,
let’s respect and preserve our cultures and missions and stay centered on the
individuals we’re serving. Many examples during the summit revealed the
ways health care and social service networks across America are partnering to
take advantage of the current opportunity. They are improving the health of the
people they serve, and continuing to carry out their core missions. That is the
path forward, and all that needs to change is the scale and pace at which we
achieve our common goal.
https://acl.gov/news-and-events/acl-blog/following-first-national-summit-heath-care-and-social-services-integration
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